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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601'E. HAZEL T ON AVE:, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t r; 11` wt (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of.the San Joaquin <br /> Local Health District' <br /> Ll q <br /> I Job Address City Lot Size —,__ - PM <br /> Owner's Name a~ h Address ' Phone <br /> 2-7 <br /> Contractor Address � - <br /> Q ® y License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ E <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I INJ <br /> I ❑ IndustrialEl❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing <br /> { ❑ Domestic/Private t,-, ❑ Gravel Pack- l El Tracy Type of Casing Specifications - <br /> ❑ Public '% � ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation A _-.'_Approx. Depth�;t❑ Eastern Surface Seal Installed by <br /> Repair Work Donel ❑ : Type of Pump H.P. State Work Done ! <br /> Well Destruction ❑i<_t Well Diameter ; Sealing Material (top 501 <br /> Depth f 'Filler Material (Below 56 <br /> TYPE OF SEPTIC WORK: NEW INSTAION K REPAIR/ADDITION L1DESTRUCTION ❑ (No septic system permitted if public sewer is , <br /> J F available within 200 feet.) <br /> Installation will serve: Residence T ,_Commercial Other ! <br />+ i Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: t,. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg a Capacity ---�No.-Compartments <br /> PKG. TREATMENT PLT. ❑ ..- Method of Disposal <br /> i Distance to nearest: Well Foundation Property Line ` <br /> I ; <br /> LINE No. & Length of lines ' 4 Tlotal length/size <br /> FILTER BE ❑ Distance to nearest: We11r�ur�f Foundation Properiy Line 7-0 f <br /> SEEPAGE PITS ❑ Depth i -Size S h _ "� Number <br /> SUMPS Ll Distance to nearest: Well '' Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application ar d,that the work will be done in accordance-with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health_Disifict, L.: x i, <br /> Home owner or licensed agent's signature certifies the following:"'I oertify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for.which this perrnit.is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for.all 9equired inspections. Complete drawing on reverse side.._ <br /> Signed X l 1 .�wM�I Titre: �+ '` - Date: r <br /> FOR DEPARTMENT USE ONLY I <br /> _ L <br /> Application Accepted by ! Date - Area <br /> Pit or Grout:lnspection by r Date Final Inspection by Date 1.115A <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369=3621 ❑ Manteca 823-7104 ❑ Tracy 8354G% f <br /> p Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201I FEE <br /> ' <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE. ' PERMIT NO. <br /> l¢ + EH 1324 4REV.t/8,5 .,.�.,� - - ._,,,� ,. .���--�/ <br /> l} f <br />